4757-5-09
Standards of ethical practice and professional conduct: record keeping.

(A)
Record keeping
requirements: For each client/consumer of services, a licensee or registrant
shall keep records of the dates of counseling, social work, or marriage and
family therapy services, types of counseling, social work, or marriage and
family therapy services, termination, and billing information. Records held by
the licensee shall be kept for seven years. Records held or owned by government
agencies or educational institutions are not subject to this requirement.
Licensees shall keep all records in a secure location and shall allow only
authorized persons access to records.

(B)
Counselors, social workers, and marriage
and family therapists shall take reasonable steps to ensure that documentation
in records is accurate and reflects the services provided. Dates reflected in
case notes shall be accurate with respect to dates of service and dates the
case notes were written. Clinical records shall include but not be limited to
appropriate diagnosis, if any; individual service plans; in-take assessments;
informed consent documents; and releases of information documents.

(C)
Counselors, social workers, and marriage
and family therapists shall include sufficient and timely documentation in
records to facilitate the delivery of services and to ensure continuity of
services provided to clients in the future.

(D)
Counselors', social workers', and
marriage and family therapists' documentation shall protect clients' privacy to
the extent that it is possible and appropriate and shall include only
information that is directly relevant to the delivery of services.

(E)
Counselors, social workers, and marriage
and family therapists shall store records following termination of services to
ensure reasonable future access. Records should be maintained as required by
this rule unless a longer retention period is required by statute or relevant
contracts

(F)
Counselors, social
workers, and marriage and family therapists shall provide clients with
reasonable access to records concerning the client. Counselors, social workers,
and marriage and family therapists who are concerned that clients' access to
their records could cause serious misunderstanding or harm to the client shall
provide assistance in interpreting the records and consultation with the client
regarding the records. Licensees should limit clients' access to their records,
or portions of their records, only in exceptional circumstances when there is
compelling evidence that such access would cause serious harm to the client.
Both the clients' requests and the rationale for withholding some or all of the
records shall be documented in the clients' files. When providing clients with
access to their records, licensees shall take steps to protect the
confidentiality of other individuals identified or discussed in such records.

(G)
A counselor, social worker, or
marriage and family therapist shall not condone, partake, or assist in billing
irregularities or fraud with respect to insurance companies or direct billing.

(H)
Counselors, social workers and
marriage and family therapists shall be aware of and adhere to divisions (H)(1)
and (H)(2) of section
3109.051 of the Revised Code.
That section in part states: "a parent of a child who is not the residential
parent of the child is entitled to access, under the same terms and conditions
under which access is provided to the residential parent, to any record that is
related to the child and to which the residential parent of the child legally
is provided access...unless the court determines that it would not be in the
best interest of the child for the parent who is not the residential parent to
have access to the records under those same terms and conditions...any keeper
of a record who knowingly fails to comply with the order or division (H) of
this section is in contempt of court." A complete reading and understanding of
this section is mandatory for any counselor, social worker or marriage and
family therapist providing services for children.

(I)
When counselors, social workers, or
marriage and family therapists leave a practice, they shall follow a prepared
plan for transfer of clients and files. Counselors, social workers, or marriage
and family therapists shall prepare and disseminate to an identified colleague
or "records custodian" a plan for the transfer of clients and files in the case
of their incapacitation, death, or termination of practice.
Each licensee responsible for client files outside of
an agency shall report to the board on the biennial registration (renewal) form
the name, address, and telephone number of a licensee or other appropriate
person knowledgeable about transfer and custody of records and responsibility
for records in the event of the licensee's absence, incapacitation or
death. Licensees at agencies that close can reference division (A)(14) of
section 5122.31 of the Revised Code for
proper transfer of records.